Provider Demographics
NPI:1093807299
Name:RILEY, JACLYN A (PT)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:A
Last Name:RILEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:A
Other - Last Name:SAMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7581 9TH ST N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6626
Mailing Address - Country:US
Mailing Address - Phone:651-747-4328
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:2334 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 170
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1858
Practice Address - Country:US
Practice Address - Phone:651-645-8083
Practice Address - Fax:651-645-8078
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist